All PlansAdministrativeHigh impact
21-622 Claims Editing Updates
Health Net·CA · Physical Therapy·Reimbursement
Effective date
Nov 15, 2021
We identified it
Jun 20, 2026
Summary
Health Net is implementing enhanced claims editing guidelines effective November 15, 2021, requiring strict compliance with CMS NCCI standards and proper use of modifiers for bilateral/multi-site procedures. New edits will deny claims missing required modifiers (especially impacting physical therapy) and expand bundling rules to match providers by ID, NPI, specialty, and TIN.
Action Required
Immediately: Billing team must update claim submission processes to ensure all bilateral/multi-site procedures include appropriate modifiers (physical therapy providers most affected). Review and update billing software to comply with expanded CMS NCCI bundling rules that now match on provider ID, NPI, specialty, and TIN. Train staff on new denial code 255 (EXwe: Procedure modifier revenue necessary) for remittance processing. Failure to include required modifiers will result in automatic claim denials.